NUFFIELD TRUST – WRITTEN EVIDENCE (PSR0041)

Public services: lessons from coronavirus

The Nuffield Trust is an independent health think tank. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis, and by informing and generating debate.

This submission draws on our expertise to answer the Committee’s important questions about the future lessons for public services from the Covid-19 pandemic. It focuses on our primary areas of expertise - health and social care - and covers four of the main fields of questioning set out in the Call for Evidence.

We examine the relations between central and local government and services, concluding that different command hierarchies and misjudged centralisation has at times shown the risks of overlooking local knowledge. Social care’s status as the poor relation of the health service, languishing without the reform universally accepted as necessary, was reflected and perpetuated as it was overlooked and its weaknesses magnified. Long term gaps in long-term investment in the NHS threw up very difficult immediate problems, highlighting the need for more strategic use of resources. At the front line, extraordinary innovation took place, but using the case study of technology in general practice we warn against being blind to its possible limitations and downsides.

The relationship between central Government and local government, and national and local services

1.1. Patterns of central and local command during the pandemic

There are significant challenges involved in organising a single response across a health service which supports almost 60 million people. It is possible to define ‘what’ should be delivered, but in many cases the ‘how’ can only be determined by local leaders who are familiar with the detail of their local areas. However, in several crucial areas this balance seems to have been wrong, with local bodies either left out or given tasks which they did not have the support to accomplish.

The Civil Contingencies Act sets out a very clear role for Local Resilience Forums[1] in establishing the response to emergencies in their areas, bringing together all relevant public and private sector stakeholders. However, it would appear that the value of these forums and the expertise of local leaders was significantly underplayed by national bodies.

The significant differences in the command structures of the health service and local authorities had consequences for the way in which the relationship between central government and local government played out through the coronavirus pandemic.

NHS England have stated that they declared a level 4 major incident[2] in relation to Covid-19 on 30th January 2020. That requires the national organisation to co-ordinate the response with all local health services and direct local leaders on the actions they were required to take – for example in freeing up hospital capacity. There is no national system of command and control in an emergency for local government, which is responsible for social care and public health. There seem to have been failings in how local authorities were supported nationally in their response to the instructions issued to the NHS.   

1.2. Implications for social care

Despite the lesson from the pandemic wargame Operation Cygnus, which showed that care homes and domiciliary care would be in need of significant support in a pandemic scenario, no advance arrangements were put in place to meet those needs. Even when the need became clear at an early stage in the coronavirus pandemic, the national response appears to have been confused and inadequate. The action plan for social care was published on 15th April.[3] This was almost a month after the action plan for health services which was issued on 17th March and had important implications for the social care sector. [4]

1.3. The establishment and ongoing management of the list of people ‘shielding’

There was a lack of clarity in roles and responsibilities between local and national bodies – NHS England, NHS Digital, CCGs and GP practices[5] – in the task of identifying vulnerable people and asking them to “shield” by staying at home more strictly than the wider population. This appears to have led to very significant variation across the country on the numbers of people being asked to shield, almost certainly going above and beyond any actual variation in the number of vulnerable individuals.[6]

It is difficult to determine the actual impact of this inconsistency on patients at this point in time. It is possible that in some areas individuals will have shielded unnecessarily whilst in others some may have been exposed to higher levels of risk. However, a widely perceived loss of confidence among GPs and other key staff, reflected in a public apology by NHS England’s Medical Director for Primary Care[7], will in itself have negative effects.

1.4. Attempts to establish a viable ‘test, track and trace’ service

The challenges in putting in place a single national approach to testing and tracking individuals who may have been exposed to coronavirus have been well documented in the press. The apparent failure by DHSC and Public Health England to engage effectively at an early stage with local Directors of Public Health is a matter of concern.

DPHs are experienced in running contact tracing systems at a local level for routine illnesses such as sexually transmitted infections. They have both the relevant technical knowledge and a deep understanding of their local communities. The fact that the Association of Directors of Public Health felt the need to publish a ‘Statement of Principles’[8] on contact tracing on May 18th, which references their disappointment at the lack of engagement by central bodies is indicative of a failure to recognise the value of local expertise and leadership in this critical part of the long term response to coronavirus.

2. Integration and working with social care

In dealing with a pandemic, particularly one whose effects hit already unwell people hardest, effective working across health and social care was shown to be crucial. Yet the Covid crisis has highlighted the stark inequities between the health and social care services. It demonstrated that effective integration requires parity of resource, equal visibility and priority in policymaking, and commitment to better data collection and sharing.

2.1. Unequal visibility and priority in policymaking

While the NHS was highly prominent in government communication about the coronavirus, references to social care were largely absent until early April and an action plan not published until 15 April 2020. Reports of discussions at SAGE meetings reveal a lack of consideration of social care and suggest a lack of integration at the highest level of decision making[9].

Although the rapid clearing of hospital beds in the early stages of the crisis offers positive lessons for how health and care can work together to facilitate discharge[10], there was too little consideration of the fragility and lack of preparedness of the care settings into which many people were being discharged.[11],[12] The belated, but narrow, focus on care homes has not been sensitive to the diversity of social care which also includes many services provided to people in their own homes.[13]

Differences in the handling of testing and PPE procurement and distribution laid bare the lack of parity between the NHS and social care. Where the NHS benefitted from centralised procurement and well-established supply chains, the fragmented nature of the social care market left individual care providers competing for PPE. As of early May, only 1,400 of 58,000 relevant organisations were able to access the national ‘portal’ for Personal Protective Equipment (PPE). [14]

NHS staff were prioritised for testing at the beginning of the pandemic, but social care staff were only able to self-refer from 24th April.  Prior guidance for symptomatic staff to self-isolate put immense pressure on a system already suffering from severe staff shortages[15]. The rollout of testing for social care users across all care settings too has been slow, and lack of testing in domiciliary care continues to be of concern among stakeholders in the sector[16].

The chronic and worsening financial and workforce problems in the social care sector, discussed below, present the backdrop to these difficulties. It is difficult to see how functional integration can take place between services so far from parity.

The devolved nations of the UK have demonstrated some divergence from England’s response in the care sector. Scotland explicitly recognised the crucial role of social care as early as 24th March, and committed to shared leadership across health and care[17]. Perhaps aided by its integrated systems, Northern Ireland redeployed staff from the NHS into social care[18] and now has plans to embed a new permanent framework for nursing and medical input into care homes[19].

2.2. Disparity in data

The systemic lack of data in social care[20] has impeded efforts to track infection rates and coordinate a response. In the absence of any established centralised data collection mechanism, deaths in care homes were not included in daily bulletins until late April[21] and mortality rates in domiciliary care remain unknown.

Sharing of data across social care, and with health, is patchy and needs to be vastly improved to facilitate integration. There is still limited understanding of the number of people in receipt of social care, how many people pay for their own care, or the types of services they are receiving. The complex structure of the social care market[22], and considerable regional variation, means there is limited understanding and oversight of it[23]. Efforts during Covid to address this have had limited success.[24] Without better data, it is unclear how services and systems can be held to account for their response and be more closely integrated with NHS services.

3. Resources, workforce and efficiency

This section examines the lessons about financing and other resources which we can draw from the experience of the coronavirus pandemic in health and social care.

3.1. NHS financing: short term bounty, long term austerity

The NHS received generous emergency funding from the Treasury during the acute phase of the Covid-19 pandemic. This enabled dramatic expansions in certain types of capacity.

However, in a number of areas long-term gaps in resources and investment are causing serious problems. Years of relatively low investment in buildings, a failure to properly fund or reform social care, and large workforce gaps continue to limit the system’s capacity in responding and recovering.

The problem of cuts in the capital, workforce and social care budgets, often in contrast to the NHS England revenue budget, has been highlighted over many years by the Nuffield Trust[25], and at various times by other impartial observers such as the Institute for Fiscal Studies.[26]

3.2. Funding and workforce in social care

Chronic underfunding of the social care system meant that it was in a fragile state before the pandemic and this hindered its ability to respond in a timely and coordinated manner. Historic workforce challenges[27] further limited the sector’s ability to respond.

Although £1.3 billion was provided to councils for short-term care packages for those discharged from hospital, and a further £1.6 billion to support all council services (social care among them), this was against a backdrop of significant chronic shortfalls in social care budgets.[28] There are concerns that the additional funding has been insufficient to fund existing care packages as well as new ones[29]. 

Unlike additional NHS funding that flowed via established mechanisms, care providers raised concerns that extra funding was not reaching them[30]. The social care provider sector is known to be fragile[31] and, with little slack in the system to respond to increased costs pressures from PPE, staff sickness and lower occupancy rates, it is likely we will witness widespread failure of the market with nobody willing to take on new clients[32]. This would lead to services being restricted to a bare minimum, further diminishing opportunities for person-centred care[33].

The picture of long-standing, well known yet neglected issues coming to the surface during the pandemic is duplicated when we look at the social care workforce. The number of vacant posts in the English social care sector had risen to 122,000 or 8% of the total workforce in 2018/19.[34] The social care action plan set out an ambition to attract 20,000 people into social care over the following three months by running a national recruitment campaign. However, the NAO recently noted that “The Department does not currently know how it is progressing against this aim”.[35]

3.3. The NHS workforce

Our review of OECD[36] and Covid Response Monitor[37] files on different countries showed that the NHS generally pursued similar strategies to other health systems across the world during the pandemic to rapidly increase the supply of workers and make best use of their skills. These steps included bringing back inactive health professionals, simplifying licensing and hiring procedures, and redeploying staff to critical care.

However, despite having a genuine impact, these short term steps cannot compensate for the chronic workforce shortages and high number of vacancies the NHS faced going into the pandemic. The gap before Covid-19 in England greatly exceeded[38] the 38,000 additional staff[39] which the Government aspires for the new policies to deliver. The NHS has fewer doctors and nurses per population than other systems and is more reliant on international recruitment than most comparable countries.[40]

These longer-term issues originate in failures of workforce planning. They will now continue to constrain the health service’s ability to return capacity to its usual level in the face of the extra tasks associated with infection control.

3.4. Buildings and capital equipment

The UK spends an unusually low amount in investing in buildings and equipment, with healthcare capital spend at around half the level of comparable countries. It has been below average for nearly all of the last twenty years.[41] This is likely to be associated with the service’s unusually low levels of MRI and CT scanners, and its low level of beds relative to the size of the population[42], although the latter has been to some extent an intentional policy.

Our interviews with health leaders show that this legacy is obstructing the service’s efforts to get core services back up and running while containing the coronavirus. Hospitals tend to have stripped out spare space: narrow corridors and A&E departments working for more people than they were designed for limit the ability to keep flows of patients separate without causing disruption. Unlike services in many other countries, NHS hospitals typically do not have individual rooms for each patient. This means entire wards will need to be set aside specifically for those who have Covid-19.[43]

4. Lessons from innovation

General practices have innovated across multiple key areas in recent years, including workforce, organisation and delivery of care, and digital technology with wider lessons for public services emerging from this. The coronavirus pandemic saw a rapid acceleration, especially in the use of digital technology. This provides an important lesson both because of the speed of these shifts, and because a good body of existing research highlights what may be some of the limits and downsides.

4.1. Changes in general practice

The coronavirus pandemic has rapidly accelerated the use of digital technology within primary care in order to enable remote ways of working, triage patients and reduce the amount of face-to-face contact in NHS settings.

The 2019 Long Term Plan set an aspiration for all general practices to offer patients remote digital consultations by 2024. NHS England stated that 99% of practices had activated remote consultation platforms where needed by May 2020.[44] [45] This has led to a sharp increase in remote appointments, particularly over the telephone. In February 2020 80% of appointments happened face to face and just 14% by telephone, but by April 2020, the proportion happening over the telephone exceeded consultations in person.[46]

The changes reflect a sense at the front line that one GP described to us as a “freedom to innovate that I’ve never before experienced”[47], with a strong motivation to change and improve among ordinary staff. The NHS leadership also played a supportive role by issuing guidance and fast tracking assurance processes.[48]

4.2. Existing evidence

It will be essential over the coming months to understand what the impact of this accelerated use of technology has been on access to and quality of care. Underlying challenges such as inadequate infrastructure and historic underinvestment[49] must also be addressed if the NHS is to continue to benefit from digital technology in the way it has throughout the pandemic.

There is some indication from existing evidence that patient-facing technology can improve care for patients and reduce strain on the NHS. However, it can also increase demand for services, disengage staff and disrupt the way that patients access care.  Use of digital technology to support self-management is unlikely to provide significant short-term cost savings.

A note of caution is needed around the high expectations from policy makers that greater use of digital technology offers a panacea for workforce challenges, or a ‘quick fix’ for improving the quality of patient care.  The balance of evidence does not support this view.

Results from large trials in primary care preceding the pandemic, and a modelling study, show that greater use of digital technology can lead to an increase in GP workload, with one study showing telephone-first triage increases GP workload by 8% on average, despite a firm policy belief that this would lead to a decrease in work for GPs.[50] [51] [52]

Digital technology works best when it embraces user-centred design.  Evidence shows that poorly designed and implemented systems can create opportunities for errors, and can result in frustrated healthcare professionals and patients.[53]